Healthcare Provider Details

I. General information

NPI: 1801103981
Provider Name (Legal Business Name): BERNADETTE BOJORGE BAEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 W KNOX DR
WASILLA AK
99654-9293
US

IV. Provider business mailing address

6821 W KNOX DR
WASILLA AK
99654-9293
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-0821
  • Fax:
Mailing address:
  • Phone: 907-373-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number28683
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number28683
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: